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At least 883 records · Page 49Linked to original sources
PubMed1980

A controlled experiment to evaluate the use of a time-oriented summary medical record.

A randomized single-blind experiment was done in a medical subspecialty clinic in order to determine whether a flow-sheet type of summary medical record could validly serve as a means to communicate clinical information in the absence of the traditional medical record. Two groups of outpatient physician-patient encounters were compared: In the 68 study encounters (Group S), physicians were given a flow-sheet summary record with the option to receive the standard medical record if they desired; in the 27 control encounters (Group C), physicians were given the standard medical record plus the flow-sheet summary record. Fifty-nine per cent of study-group physicians did not choose to receive the full medical record. The study group was found not to differ (p = 0.013) from controls significantly with regard to the follow-up of clinical information as measured by pre- and post-encounter chart review. Physician providers in the study group were unable to detect by retrospective chart review overlooked clinical information with greater frequency than control group providers. We conclude that a flow-sheet type of summary medical record can serve as the sole source of clinical information in a substantial number of outpatient follow-up encounters in a medical subspecialty clinic without deterioration in the communication of clinical information.

Ambulatory Care Facilities↗
PubMed1991

Validation of information recorded on general practitioner based computerised data resource in the United Kingdom.

OBJECTIVE: To determine the extent of agreement between clinical information recorded on surgery computers of selected general practitioners and similar information in manual records of letters received from hospital consultants and kept in the general practitioners' files. DESIGN: Hospital consultants' letters in the manual records of selected general practitioners were photocopied and the consultants' clinical diagnoses were compared with diagnoses recorded on computer. SETTING: General practices in the United Kingdom using computers provided by VAMP Health for recording clinical information. SUBJECTS: 2491 patients who received one of three non-steroidal anti-inflammatory drugs and who attended 58 practices whose computer recorded data were considered after a preliminary review to be of satisfactory quality. RESULTS: Among 1191 patients for whom consultants' letters were forwarded a clinical diagnosis reflecting the diagnosis noted on a consultant letter was present on the computer record for 1038 (87%). CONCLUSION: Clinical information available on the computer records of the general practitioners who participated in this study is satisfactory for many clinical studies.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed1993

Why and how to establish a computerized system for psychiatric case records.

Based on experience with successful implementation of an on-line computerized psychiatric case record system in a psychiatric hospital in Israel, the authors discuss the advantages of such systems and outline the process of converting paper records to computerized records. Computerized records can save time by automatically issuing routine reports, improve clinical practice, simplify quality assurance, and ease collection and analysis of data for research. The process of converting paper records to computerized records can begin with analysis of the hospital's reporting requirements and creation and pilot testing of structured paper forms with a multiple-choice format that is eventually incorporated into the computer program. The authors recommend an on-line computerized record system with direct input of data because such a system can be used for case audits and can generate reports, treatment plans, and medication orders without removing records from circulation. Other advantages include the system's usefulness in electronic communication within and outside the hospital.

Attitude of Health Personnel↗
PubMed2005

Computerised versus handwritten records.

The death of Victoria Climbié highlighted the worst possible consequences of inadequate record keeping. A serious case review raised concerns about the quality of record keeping in the paediatric intensive care unit (PICU) of a large UK children's hospital and an audit was undertaken to compare the standard of handwritten nursing records in the PICU with that of the computerised nursing records in the high dependency unit (HDU). Record keeping in both PICU and HDU was found to be sub-standard in many respects. Both types of record keeping have their faults but the computerised system can potentially compensate for some of the errors and omissions that were apparent in the handwritten records. Nurses require regular training to reinforce record keeping knowledge and skills: this has been incorporated into the hospital's mandatory training programme.

Abbreviations as Topic↗
PubMedDate not supplied

Standards in medical record keeping.

Medical records serve many functions but their primary purpose is to support patient care. The RCP Health Informatics Unit (HIU) has found variability in the quality of records and discharge summaries in England and Wales. There is currently a major drive to computerise medical records across the NHS, but without improvement in the quality of paper records the full benefits of computerisation are unlikely to be realised. The onus for improving records lies with individual health professionals. Structuring the record can bring direct benefits to patients by improving patient outcomes and doctors' performance. The HIU has reviewed the literature and is developing evidence-based standards for record keeping including the structure of the record. The first draft of these standards has been released for consultation purposes. This article is the first of a series that will describe the standards, and the evidence behind them.

Forms and Records Control↗
PubMed2001

Ranking of information in the computerized problem-oriented patient record.

We propose a framework for a problem-oriented patient record for general practice 1 and defend that the problem-oriented medical record represents an intuitive way to organize the patient record. By adding a layer of knowledge to the electronic patient record the record system is able to better utilize the information stored in the record. If a record system is process aware, having knowledge of work processes and is able to distinguish between different contexts in use, the system can provide relevant and useful information during the handling of patients' medical problems. Information is ranked according to its relevancy in a given context by using action patterns - traces. Traces give valuable indications of what is going on during the process of patient care. Decision frames represents relevant contexts based on the information in the record. Both decision frames and traces provide an environment in which more optimal medical decisions can be made.

Artificial Intelligence↗
PubMed1992

Retention of patient records.

Patient records are essential to provide patients with appropriate health care and to preserve patients' rights. Patient records are also vital to help practitioners defend lawsuits. Therefore, practitioners must maintain patient records in good order for as long as possible. This paper discusses the clinical and legal issues involved in record retention, including the relevant state regulations and record requirements in other health care fields, to provide guidelines for retention of optometric patient records. Based on the statutes of limitations, common practice and sound medical and legal advice, optometric patient records should be retained for a minimum of 10 years after the patient was last seen. Ideally, patient records should be retained forever.

Humans↗
PubMed1982

The utility for audit of manual and computerized problem-oriented medical record systems.

Objective assessment of the delivery of care requires an unambiguous record of all related events and decisions in the care process. Both the handwritten Problem-Oriented Medical Record (POMR) and its computerized successor, the Problem Oriented Medical Information System (PROMIS) have been designed to facilitate audit of care delivery. In this study, a national sample of physicians was asked to determine which of these two record systems best serves the function of audit. The study involves assessment of a sample of 69 matched pairs of patient records drawn from two different ward settings, one of which used the manual POMR, the other, PROMIS. No difference was perceived between the two records with respect to the reliability of information or the analytical reasoning of providers. Information in PROMIS records was judged to be slightly more thorough. The format of the manual record was judged better on the basis of conciseness, accessibility, and organization of record information.

Computers↗
PubMed1995

A distributed, scalable, community care network architecture for wide-area electronic patient records: modeling and simulation.

Principal systems issues relative to computerizing patient medical records that are yet to be addressed in the scientific literature include (1) the characteristics of networks, i.e. bandwidth and capacity, and their impact on the performance of the system, (2) the architecture and the underlying algorithm of the system, (3) the location and migration of medical records, (4) scalability of the system, and (5) the nature of the performance variation under heavy and light use of the network. Key parameters that affect performance include the number of patients, doctors, frequency of patient visits, and the number of electronic queries and record entries initiated during a patient-doctor interaction episode. This paper presents AMPReD, a Distributed, Scalable, Community Care Network Architecture that aims to provide Real-Time Access to Geographically-Dispersed Patient Medical Records. The AMPReD model includes stationary hospitals and medical clinics, mobile clinics, migrating doctors as well as patients, the communications network, and the patient medical record database. AMPReD's goals include (1) the accurate modeling of the propagation of medical records and (2) providing real-time access to patient medical records from anywhere in the system. To achieve these goals, an asynchronous, distributed algorithm must be developed that achieves concurrent access of multiple, autonomous databases. AMPReD is modeled and simulated for a representative community care network on a network of workstations configured as a loosely-coupled parallel processor, for different parametric combinations of number of doctors, patients, and number of queries or record entries generated corresponding to every patient-doctor interaction episode. AMPReD defines and obtains key performance measures including the idle times of the doctors, patient waiting times, the access times of queries as functions of their sizes, and the growth of the databases. In addition, AMPReD also measures the deviation of the actual time required for a patient-doctor interaction episode from the scheduled interaction interval, as a function of the network load. For the representative system selected, performance measures indicate that the network, utilizing 1/2T1 links, and the database system poses no bottleneck to the system even where the number of doctors and patients within a 30 minute interval are chosen at 192 and 200 respectively. A T1 is a standard, digital, transmission link that is rated at 1.44Mbits/sec.

Algorithms↗
PubMed1995

A shared computer-based problem-oriented patient record for the primary care team.

1. INTRODUCTION. A computer-based patient record (CPR) system, Swedestar, has been developed for use in primary health care. The principal aim of the system is to support continuous quality improvement through improved information handling, improved decision-making, and improved procedures for quality assurance. The Swedestar system has evolved during a ten-year period beginning in 1984. 2. SYSTEM DESIGN. The design philosophy is based on the following key factors: a shared, problem-oriented patient record; structured data entry based on an extensive controlled vocabulary; advanced search and query functions, where the query language has the most important role; integrated decision support for drug prescribing and care protocols and guidelines; integrated procedures for quality assurance. 3. A SHARED PROBLEM-ORIENTED PATIENT RECORD. The core of the CPR system is the problem-oriented patient record. All problems of one patient, recorded by different members of the care team, are displayed on the problem list. Starting from this list, a problem follow-up can be made, one problem at a time or for several problems simultaneously. Thus, it is possible to get an integrated view, across provider categories, of those problems of one patient that belong together. This shared problem-oriented patient record provides an important basis for the primary care team work. 4. INTEGRATED DECISION SUPPORT. The decision support of the system includes a drug prescribing module and a care protocol module. The drug prescribing module is integrated with the patient records and includes an on-line check of the patient's medication list for potential interactions and data-driven reminders concerning major drug problems. Care protocols have been developed for the most common chronic diseases, such as asthma, diabetes, and hypertension. The patient records can be automatically checked according to the care protocols. 5. PRACTICAL EXPERIENCE. The Swedestar system has been implemented in a primary care area with 30,000 inhabitants. It is being used by all the primary care team members: 15 general practitioners, 25 district nurses, and 10 physiotherapists. Several years of practical experience of the CPR system shows that it has a positive impact on quality of care on four levels: 1) improved clinical follow-up of individual patients; 2) facilitated follow-up of aggregated data such as practice activity analysis, annual reports, and clinical indicators; 3) automated medical audit; and 4) concurrent audit. Within that primary care area, quality of care has improved substantially in several aspects due to the use of the CPR system [1].

Ambulatory Care Information Systems↗
PubMed1998

Effects of record linkage errors on disease registration.

Reliable record linkage is a prerequisite for high-quality population-based disease registration. Rapid developments in computer processing have made record linkage both more efficient and more reliable in recent years. At the same time, concerns about confidentiality increasingly hinder record linkage in many disease registries. This paper provides basic algebraic models describing the effects of record linkage errors on monitoring disease incidence. Homonym errors, that is, erroneous linkage of records that pertain to distinct individuals, lead to underestimation of incidence in the registry population. The degree of underestimation strongly depends on the discriminating power of personal identifiers and the record linkage procedure on the one hand, and the number of registered cases on the other hand. Synonym errors, that is, failure to link notifications on the same individual, lead to overestimation of incidence in the population base. The combined effects of record linkage errors are illustrated with empirical examples. We conclude that it is the largest and most informative disease registries that are potentially affected most by impediments of record linkage procedures due to unduly restrictive confidentiality rules.

Disease Notification↗
PubMed1998

Evidence-based well-baby care. Part 1: Overview of the next generation of the Rourke Baby Record.

PROBLEM BEING ADDRESSED: Well baby and child care in the primary care setting has not always been based on evidence that has been shown to be effective in preventing and detecting disease and injury. OBJECTIVE OF THE PROGRAM: To help physicians and nurses provide care that is more effective than a routine complete examination, the Rourke Baby Record has been revised to include evidence-based recommendations for preventive care for infants and young children. The revision incorporates the approach and recommendations of the Canadian Task Force on the Periodic Health Examination. The updated record is now called the Rourke Baby Record: Evidence-Based Infant/Child Health Maintenance Guide (Rourke Baby Record: EB). MAIN COMPONENTS OF PROGRAM: Part 1 of this two-part article briefly describes the background for development and presents an overview of the revised record. Part 2 discusses in detail the evidence that exists for maneuvers included in the education and advice section of the revised record. CONCLUSION: Using the Rourke Baby Record: EB and incorporating it into their office record systems as a working guide will help increase the effectiveness of the primary preventive care physicians provide to infants and young children.

Child↗
PubMedDate not supplied

An automated procedure for determining patient numbers from episode of care records.

Records of in-patient stays which may contain multiple entries for the same patient are linked. These provide a profile of all in-patient hospital contacts for the same patient and statistics from which prevalence measures can be estimated. The linkage procedure is designed to link Scottish Morbidity Records for patients of the Greater Glasgow Health Board. It is suited to in-patient records generated from a relatively small number of hospitals (25-30). The records are selected by diagnosis. A suite of computer programs automates the method, which was initially investigated manually. Two types of linkage are performed. Type 1 links on the unique identifiers of hospital group code and case reference number to link records from the same hospital or group of hospitals. Type 2 linkage is designed to link patient stays in different hospitals or groups and links records with identical surname and date of birth and then identical surname and full unit postcode. The accuracy and efficiency of the automated procedure was estimated by linking records for 6 diagnoses (lung cancer, ischaemic heart disease, cerebrovascular disease, infectious diseases, road traffic accidents and head injuries). The gross difference between the actual number of patients and the number after linkage was between 0.6 and 2.1%. The net difference was within 1% for all diagnoses except lung cancer with a difference of 1.3%. These results compare favourably with other linkage procedures.

Hospital Information Systems↗
PubMed1993

Feasibility of ensuring confidentiality and security of computer-based patient records. Council on Scientific Affairs, American Medical Association.

Legal and ethical precepts that apply to paper-based medical records, including requirements that patient records be kept confidential, accurate and legible, secure, and free from unauthorized access, should also apply to computer-based patient records. Sources of these precepts include federal regulations, state medical practice acts, licensing statutes and the regulations that implement them, accreditation standards, and professional codes of ethics. While the legal and ethical principles may not change, the risks to confidentiality and security of patient records appear to differ between paper- and computer-based records. Breaches of system security, the potential for faulty performance that may result in inaccessibility or loss of records, the increased technical ability to collect, store, and retrieve large quantities of data, and the ability to access records from multiple and (sometimes) remote locations are among the risk factors unique to computer-based record systems. Managing these risks will require a combination of reliable technological measures, appropriate institutional policies and governmental regulations, and adequate penalties to serve as a dependable deterrent against the infringement of these precepts.

Computer Security↗
PubMed1998

Cost-effectiveness of hospital discharge records for reaching selected endpoints in the surveillance of silicosis.

BACKGROUND: The Sentinel Event Notification System for Occupational Risks (SENSOR) is a state/federal system for the surveillance and intervention of occupational conditions. The Ohio SENSOR program identifies silicosis cases from a number of data sources, although hospital discharge records have largely been considered the most successful means of carrying out SENSOR objectives. However, the cost-effectiveness of hospital discharge records has not been evaluated. Thus, a cost analysis was conducted to compare the effectiveness of hospital discharge records with other data sources for achieving prevention-related endpoints of silicosis surveillance. METHODS: Total costs of reaching three endpoints (obtaining case names, identifying work sites, and identifying silica problems in work sites) were estimated retrospectively and measured in 1996 dollars for four data sources: hospital discharge records, physician reports, workers' compensation claims, and death certificates. Total costs were then divided by output for each source/endpoint combination to produce estimates of average costs. RESULTS: The average cost per case was $30 for hospital records, $212 for physician reports, $19 for workers' compensation claims, and $7 for death certificates. However, for identifying problem work sites, hospital records were most expensive at $2,883 per work site, compared with $2,558 for physician reports, $1,318 for workers' compensation claims, and $1,310 for death certificates. CONCLUSIONS: Hospital discharge records were least cost-effective for accomplishing prevention-related goals of surveillance. A change in the mix of resources applied to silicosis surveillance and intervention under SENSOR, i.e., a shift away from follow-up of hospital records toward more cost-effective methods for identifying work sites with silica problems may result in more efficient use of public health resources devoted to the prevention of silicosis.

Cost-Benefit Analysis↗
PubMed1992

Eight year's experience with automated anesthesia record keeping: lessons learned--new directions taken.

For the past eight years, an automated anesthesia record keeping system, COMANDAS (COMputerized ANesthesia Data Acquisition System) has been used in the cardiovascular operating rooms at Mayo Clinic. The automated anesthesia record is designed to match the traditional hand-written record and becomes part of the official medical record. COMANDAS is interfaced with the physiologic monitor and mass spectrometer in each OR, and a number of other computers within the Mayo Medical Center. Since the introduction of COMANDAS over 24,000 surgical procedures have been charted. The anesthesia record is more complete, consistent in organization, and legible when compared to a hand-written record. Recently, it was determined that the computers and peripherals that make up COMANDAS were wearing out and that the vendors would no longer support or replace the equipment. A process to find a replacement for COMANDAS was then begun. Although the cardiovascular anesthesia group was satisfied with the automated anesthesia record, there were a number of areas in which improvement was desired. A systematic evaluation of the system was begun with a survey of the users. The majority of those surveyed felt that COMANDAS was a useful system which made parts of their job easier. The user interface, method of manual data entry, time to produce the record and difficulty learning the system were the source of the greatest dissatisfaction. Artifacts, networking, interfacing with other devices and computers were also issues for the replacement system. Most commercial systems were found wanting in one or more areas of significance. The most practical solution appeared to be the modification of a currently available intensive care unit patient data management system.

Anesthesiology↗
PubMed1998

[Artificial bradycardias due to tape-running problems of old long-term ECG records].

Artificial bradycardias due to tape-running alterations of old long-term ECG recorders were observed with increasing frequency in the last 2 years at our hospital. To document the extent of this problem, 115 consecutive 24-hour long-term ECG recordings of 10 still used tape recorders with an age of 12 +/- 4 years were examined. Analysis of the tapes with a new analysis system revealed artificial bradycardias with rates of 10 to 40/min in 22 of 115 long-term ECG recordings (19%). These artificial bradycardias were observed in 4 out of 10 examined tape recorders (40%). Three of 4 concerned recorders were 14 years old at the time of examination, and one recorder was only 5 years old. Artificial bradycardias were caused by extensive alterations of tape-running speed in all cases. Diagnostic proof of artificial bradycardias due to tape running alterations on long-term ECG are simultaneous with prolonged RR-intervals occurring increases in all ECG times including P-width. PQ-time, QRS-width and QT-duration with otherwise unchanged ECG morphology. To avoid prolonged hospital stays or therapeutic mistakes like unnecessary pacemaker implantation, especially older long-term ECG-tape recorders should be checked regularly and, if necessary, be replaced by new devices.

Artifacts↗
PubMed2001

[Electronic versus paper-based patient records: a cost-benefit analysis].

BACKGROUND: The aim of this study is to compare the costs and benefits of electronic, paperless patient records with the conventional paper-based charts. METHODS: Costs and benefits of planned electronic patient records are calculated for a University eye hospital with 140 beds. Benefit is determined by direct costs saved by electronic records. RESULTS: In the example shown, the additional benefits of electronic patient records, as far as they can be quantified total 192,000 DM per year. The costs of the necessary investments are 234,000 DM per year when using a linear depreciation over 4 years. In total, there are additional annual costs for electronic patient records of 42,000 DM. Different scenarios were analyzed. By increasing the time of depreciation to 6 years, the cost deficit reduces to only approximately 9,000 DM. Increased wages reduce the deficit further while the deficit increases with a loss of functions of the electronic patient record. However, several benefits of electronic records regarding research, teaching, quality control and better data access cannot be easily quantified and would greatly increase the benefit to cost ratio. CONCLUSION: Only part of the advantages of electronic patient records can easily be quantified in terms of directly saved costs. The small cost deficit calculated in this example is overcompensated by several benefits, which can only be enumerated qualitatively due to problems in quantification.

Cost-Benefit Analysis↗